E3067 Which Details

In this blog post, I will be discussing the SciF E3067 form. This is a form that is used to document the results of an evaluation for a specific scientific inquiry. The purpose of this form is to provide information on the investigation, the methods used, and the findings of the study. The SciF E3067 form can be used by researchers and scientists to document their findings, and it can also be used as a tool for quality assurance. In my previous blog posts, I have discussed the different types of scientific forms that are used in research, so if you are interested in learning more about those forms, I would recommend checking out those posts.

You'll find it useful to know the amount of time you'll need to complete this scif e3067 form and exactly how lengthy this document is.

QuestionAnswer
Form NameScif E3067 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesscif rev, form 3067 fill, scif e3067, e3067 rev

Form Preview Example

State of California

EMPLOYER'S REPORT

OF OCCUPATIONAL INJURY OR ILLNESS

STATE COMPENSATION INSURANCE FUND

24-Hour Claims Reporting Center

Telephone: (888) 222-3211 Fax (800) 371-5905

OSHA

Case No.

Fatality

Any person who makes or causes to be made any

 

NOTICE: California law requires employers to report within five days of knowledge every occupational injury or illness

 

knowingly false or fraudulent material statement

 

which results in lost time beyond the date of the incident OR requires medical treatment beyond first aid. If an employee

 

 

or material representation for the purpose of

 

subsequently dies as a result of a previously reported injury or illness, the employer must file within five days of knowledge

 

 

obtaining or denying workers' compensation

 

an amended report indicating death. In addition, every serious injury, illness, or death must be reported immediately by

 

 

benefits or payments is guilty of a felony.

 

 

telephone or telegraph to the nearest office of the California Division of Occupational Safety and Health.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. FIRM NAME

 

 

 

 

 

 

 

 

DIVISION

 

 

1a. Policy Number

 

 

 

Please do

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

not use this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Column

E

2. MAILING ADDRESS (Number and Street, City, Zip)

 

 

 

 

 

 

 

 

 

 

2a. Phone Number

 

 

 

Case Number

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. LOCATION, if different from Mailing Address (Number, Street, City and Zip)

 

 

 

 

 

 

3a. Location Code

 

 

 

Ownership

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

4. NATURE OF BUSINESS; e.g., Painting contractor, wholesale grocer, sawmill, hotel, etc.

 

 

 

 

 

 

5. STATE UNEMPLOYMENT INSURANCE

Industry

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACCT. NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. TYPE OF EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PRIVATE

STATE

COUNTY

 

CITY

 

SCHOOL DIST.

 

OTHER GOVERNMENT - SPECIFY ____________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7. DATE OF INJURY / ONSET OF ILLNESS

8. TIME INJURY/ILLNESS OCCURRED

9. TIME EMPLOYEE BEGAN WORK

 

10. IF EMPLOYEE DIED, DATE OF DEATH

Sex

 

 

(mm/dd/yy)

 

 

 

________ A.M.

 

________ P.M.

 

 

 

 

 

 

(mm/dd/yy)

 

 

 

 

 

 

 

 

 

 

 

 

________ A.M. ________ P.M.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11. UNABLE TO WORK FOR AT LEAST ONE

12. DATE LAST WORKED (mm/dd/yy)

 

13. DATE RETURNED TO WORK

 

14. IF STILL OFF WORK, CHECK THIS

Age

 

 

FULL DAY AFTER

YES

NO

 

 

 

 

 

 

(mm/dd/yy)

 

 

 

 

BOX

 

 

 

 

 

 

DATE OF INJURY?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15. PAID FULL DAY'S WAGES FOR DATE OF

16. SALARY BEING CONTINUED?

 

17. DATE OF EMPLOYER'S KNOWLEDGE/

18. DATE EMPLOYEE WAS PROVIDED

Daily hours

I

 

INJURY OR LAST

YES

NO

 

 

YES

 

NO

 

NOTICE OF INJURY/ILLNESS (mm/dd/yy)

 

CLAIM FORM (mm/dd/yy)

 

 

 

N

 

DAY WORKED?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J

19. SPECIFIC INJURY/ILLNESS AND MEDICAL DIAGNOSIS if available, e.g., Second degree burns on right arm, tendonitis on left elbow, lead poisoning.

19a. BODY PART AFFECTED

Days per Week

U

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20. LOCATION WHERE EVENT OR EXPOSURE OCCURRED (Address)

20a. ZIP

20b. COUNTY

 

21. ON EMPLOYER'S PREMISES?

21a. WAS ANOTHER PERSON

 

Y

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

RESPONSIBLE?

 

 

Weekly Hours

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

O

 

22. DEPARTMENT WHERE EVENT OR EXPOSURE OCCURRED, e.g., Shipping department, machine shop.

 

 

23. OTHER WORKERS INJURED OR ILL IN THIS EVENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

R

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

Weekly Wage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24. EQUIPMENT, MATERIALS AND CHEMICALS THE EMPLOYEE WAS USING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Acetylene, welding torch, farm tractor, scaffold.

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. SPECIFIC ACTIVITY THE EMPLOYEE WAS PERFORMING WHEN EVENT OR EXPOSURE OCCURRED, e.g., Welding seams of metal forms, loading boxes onto truck.

County

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

26. HOW INJURY/ILLNESS OCCURRED. DESCRIBE SEQUENCE OF EVENTS. SPECIFY OBJECT OR EXPOSURE WHICH DIRECTLY PRODUCED THE INJURY/ILLNESS,

 

S

 

e.g., Worker stepped back to inspect work and slipped on scrap material. As he fell, he brushed against fresh weld, and burned right hand. USE SEPARATE SHEET IF NECESSARY.

 

 

Nature of Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

S

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27. NAME AND ADDRESS OF PHYSICIAN (Number, Street, City, Zip)

 

 

 

 

 

 

 

 

27a. Phone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28. HOSPITALIZED AS AN INPATIENT OVERNIGHT?

 

NO

YES If yes, then, NAME AND ADDRESS OF HOSPITAL (Number,

28a. Phone Number

 

 

 

Part of body

 

 

Street, City, Zip)

 

 

 

 

 

 

 

 

(Number, Street, City, Zip)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

29. Employee treated in Emergency Room?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

ATTENTION: This form contains information relating to employee health and must be used in a manner that protects the confidentiality of employees to the extent possible while

 

the information is being used for occupational safety and health purposes. See CCR Title 8 14300.29 (b)(6)-(10) & 14300.35(b)(2)(E)2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source

Note: Shaded boxes indicate confidential employee information as listed in CCR Title 8 14300.35(b)(2)(E)2.*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

30. EMPLOYEE NAME

 

 

 

 

 

 

 

 

31. SOCIAL SECURITY NUMBER

 

32. DATE OF BIRTH (mm/dd/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Event

E

 

33. HOME ADDRESS (Number, Street, City, Zip)

 

 

 

 

 

 

 

 

 

 

 

33a. PHONE NUMBER

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

34. SEX

 

 

35. OCCUPATION (Regular job title, NO initials, abbreviations or numbers)

 

36. DATE OF HIRE (mm/dd/yy)

 

 

Secondary

L

 

 

 

 

 

 

 

MALE

FEMALE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source

O

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

37. EMPLOYEE USUALLY WORKS

 

 

 

 

37a. EMPLOYMENT STATUS

disabled

unemployed

37b. UNDER WHAT CLASS CODE OF YOUR

 

E

 

 

 

 

 

 

 

 

regular, full-time

part-time

retired

on strike

 

POLICY WERE WAGES ASSIGNED?

 

 

hours

days

 

 

total

 

 

Extent of Injury

 

 

 

 

 

 

 

 

 

 

 

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______per day

________per week _________weekly hours

 

temporary

 

seasonal

laid-off

other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

38. GROSS WAGES/SALARY

 

 

 

 

39. OTHER PAYMENTS NOT REPORTED AS WAGES/SALARY (e.g., tips, meals, overtime,

 

 

 

 

 

 

$ ___________________ per ___________________

 

bonuses, etc.)?

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

40. Number of employees on most recent policy inception or renewal date in effect at time of injury.

 

 

 

 

 

 

 

 

 

 

 

Date (mm/dd/yy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Completed By (type or print)

 

 

 

 

 

 

 

Signature & Title

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

* Confidential information may be disclosed only to the employee, former employee, or their personal representative (CCR Title 8 14300.35), to others for the purpose of processing a workers' compensation or other insurance claim: and under certain circumstances to a public health or law enforcement agency or to a consultant hired by the employer (CCR Title 8 14300.30). CCR Title 8 14300.40 requires provision upon request to certain state and federal workplace safety agencies.

SCIF e3067 (REV. 9-07)

FILING OF THIS REPORT IS NOT AN ADMISSION OF LIABILITY. A CLAIM FORM MUST BE GIVEN TO THE INJURED WORKER WITHIN ONE

 

WORKING DAY OF YOUR KNOWLEDGE OF OCCUPATIONAL INJURY OR ILLNESS WHICH RESULTS IN LOST TIME OR MEDICAL TREATMENT.